Integrated Outpatient Code Editor (OCE) and Medicare Code Editor (MCE)

CMS created two code editors to process UB-04 claims which are:

Integrated Outpatient Code Editor (OCE)

The Integrated Outpatient Code Editor (IOCE) program processes claims for all outpatient institutional providers including hospitals subject to the Outpatient Prospective Payment System (OPPS) and Non-OPPS hospitals, such as Critical Access Hospitals (CAHs). Within the IOCE there are currently 98 different edits used to validate claims and apply appropriate payment for both OPPS and Non-OPPS outpatient claims. The returned edit numbers are associated with reason codes viewable in Direct Data Entry (DDE) based on the specific CPT/HCPCS codes, modifiers and diagnosis codes listed on the claim. Providers can locate the 98 edits and the descriptions.

  • Go to CMS OCE Quarterly Release Files
  • Under desired quarter, select/open "IOCE QuarterlyDataFiles" 
  • Within zip files, select "IntegOCEspecsV172_508.pdf"
  • View "Table 4: Edit Descriptions"

Noridian has received numerous calls from providers indicating many providers have internal firewalls that prevent downloading of these documents. Providers must work with their internal IT staff to download these documents.

The IOCE functions on a single claim and does not have any cross claim capabilities. It will accept up to 450 line items per claim. Updates are made to the IOCE on a quarterly basis and the IOCE edits identify:

  • Claim errors
  • What claim actions are needed, if applicable
  • Reasons why claim actions are necessary

IOCE assigns an Ambulatory Payment Classification (APC) number for each service covered under OPPS. In order to accommodate editing, the IOCE assigns status indicators to all lines and assigns payment indicators when all editing is passed allowing processing and payment on the services billed. Each lines' SI flags can be located in DDE or in the CMS Addendum B.

IOCE will:

  • Compute payment
  • Discount/package all services included in the APC payment
  • Determine any payment adjustments required based on the APC

Providers can locate IOCE Software Installation and User Manual for PC

It is separated into ten chapters and five appendices.

  • Go to CMS OCE Quarterly Release Files
  • Under appropriate quarter, select/open "IOCE PC Software Package" 
  • When zip file populates, select "IOCE.V172.R0.PC.Man_508.P.zip"
  • Select "pbl021 IOCE v17.2 PC_508.pdf"

Note: Noridian has received numerous calls from providers indicating many providers have internal firewalls that prevent downloading of these documents. Providers must work with their internal IT staff to download these documents.

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Chapter 1: Introduction to the Integrated OCE software
  • Product background
  • Versions of the program
  • Included versions
  • Purpose of the OPPS functionality
  • Purpose of the non-OPPS functionality
  • Changes since OPPS
  • Coding for Outpatient services
  • Program input
  • Dispositions
  • Multiple day claims
  • Edits
  • Information on APCs for OPPS
  • Payment information
  • Packaging
  • Discounting
  • NCCI
  • Fee schedule
  • Status indicators
  • Modifiers
  • Same day medical and procedure APC
  • Same day multiple E&M codes
  • Home health, and hospice care
Chapter 2: Installing the software
  • Minimum system requirements
  • Other supported platforms
  • Pre-installation notes
  • Installation and update procedure
  • Uninstalling the software
Chapter 3: OPPS data entry
  • OPPS data entry
  • OPPS Menu items
  • OPPS command buttons
  • OPPS error messages
Chapter 4: OPPS data output
  • Viewing an output report
  • Output report fields
  • Menu items from the output report window
  • Dispositions
  • Edit disposition
  • Claim disposition
  • Edit disposition summary
Chapter 5: OPPS program edits
  • Special logic information
  • Inpatient procedures
  • Drug administration
  • Observation
  • Wound care
  • Implantation of replacement devices
  • Special packaging
  • Critical care packaging
  • Deductible and co-insurance payment adjustment
  • Trauma response critical care
  • Composite APCs
  • Nuclear medicine procedures and radiolabeled products
  • Partial hospitalization
  • Managed care beneficiaries
  • Hospice claims
  • Skin substitute products
  • Packaged laboratory codes
  • FQHC claims under PPS
  • Comprehensive APCs
  • CT scan equipment not meeting NEMA standards
  • Advance care planning
  • Pass-through device offset
  • Pass-through Drugs and Biologicals Offset
Chapter 6: Non-OPPS data entry
  • Versions and date ranges
  • Accessing the software
  • Non-OPPS data entry fields
  • Non-OPPS menu items
  • Non-OPPS command buttons
  • Non-OPPS error messages
Chapter 7: Non-OPPS data output
  • Viewing an output report
  • Output report fields
  • Menu items from the output report window
  • Payment information
  • Dispositions
  • Edit disposition
  • Claim disposition
  • Edit disposition summary
Chapter 8: Non-OPPS program edits
  • Special logic information
  • ASC procedure codes
Chapter 9: Batch processing
  • Batch input
  • Input record layouts
  • Batch output
  • Output record formats
  • Log file
  • Error messages
Chapter 10: Accessibility features
  • System requirements
  • Data entry
  • Data entry fields
  • Data entry menu items
  • Input window command buttons
  • Error messages
  • Program output
  • Viewing an output report
  • Output report fields
  • Output report menu items
  • Output report command button
  • Program edits
  • Dispositions
  • Edit disposition
  • Claim disposition
  • Edit disposition summary
Appendix A: Diagnosis edit code lists
  • Adult diagnoses (ICD-10 CM codes)
  • Newborn diagnoses (ICD-10 CM codes)
  • Pediatric diagnoses (ICD-10 CM codes)
  • Maternity diagnoses (ICD-10 CM codes)
  • Diagnoses for females only (ICD-10 CM codes)
  • Diagnoses for males only (ICD-10 CM codes)
  • Manifestation diagnoses (ICD-10 CM codes)
  • Mental health diagnoses (ICD-10 CM codes)
  • Adult diagnoses (ICD-9 CM codes)
  • Newborn diagnoses (ICD-9 CM codes)
  • Pediatric diagnoses (ICD-9 CM codes)
  • Maternity diagnoses (ICD-9 CM codes)
  • Diagnoses for females only (ICD-9 CM codes)
  • Diagnoses for males only (ICD-9 CM codes)
  • Manifestation diagnoses (ICD-9 CM codes)
  • Mental health diagnoses (ICD-9 CM codes)
Appendix B: Procedure edit code lists
  • Procedures for females only
  • Procedures for males only
  • Non-covered under any Medicare outpatient benefit (based on statute)
  • Non-covered under any Medicare outpatient benefit (based on other than statute)
  • Questionable covered service
  • Inpatient procedures
  • Inpatient separate procedure
  • Code not recognized by Medicare for outpatient claims
  • Non-implantable DME
  • Code not recognized by OPPS
  • Service not billable to MAC
  • Mental Health services not approved for Partial Hospitalization Program
  • Mental Health services not payable outside Partial Hospitalization Program
  • Add-on/Primary Procedure Pairs
  • Skin substitute procedures and products - low cost
  • Skin substitute procedures and products - high cost
  • Device procedures
  • Devices
Appendix C: Other code lists
  • STV-packaged services code list
  • T-packaged services
  • Critical care-packaged
  • Partial hospital program services (List A and B)
  • Mental health services composite list
  • Comprehensive APC Complexity Adjusted Code Pairs
  • FQHC Encounter/Qualifying Visit Code pairs
  • Pass-through contrast
  • Pass-through radiopharmaceutical
Appendix D: List of APCs
  • List of APCs
Appendix E: Summary of changes
  • Software
  • Edits
  • Files
  • Tables
  • Documentation

 

Edit Dispositions

  • Claim rejection - The provider can correct and resubmit the claim but cannot appeal the rejection.
  • Claim denial - The provider cannot resubmit the claim but can appeal the denial.
  • Claim return to provider (RTP) - The provider can resubmit the claim once the problems are corrected.
  • Claim suspension - The claim is not returned to the provider, but it is not processed for payment until the fiscal intermediary/Medicare Administrative Contractor (FI/MAC) makes a determination or obtains further information.
  • Line item rejection - The claim can be processed for payment with some line items  rejected for payment (i.e., the line item can be corrected and resubmitted but cannot be appealed).
  • Line item denial - There are one or more edits that cause one or more individual line items to be denied. The claim can be processed for payment with some line items denied for payment (i.e., the line item cannot be resubmitted but can be appealed).

Medicare Code Editor (MCE)

The MCE is the inpatient code editor and is used to detect claim errors based on coding listed on UB-04 claims submitted to Medicare.

Access CMS MCE Manual

  • Go to CMS Acute Inpatient Prospective Payment System (IPPS)
  • In left hand navigation menu, select desired year for "FY IPPS Final Rule Home Page"
  • In table, select desired year for  "FY Final Rule and Correction Notice Data Files" 
  • Scroll to "Downloads" section
  • Select "Definition of Medicare Code Edits v33" zip file
  • Select/open "ICD-10 Definitions of Medicare Code Edits_v33.0.pdf"

Noridian has received numerous calls from providers indicating many providers have internal firewalls that prevent downloading of these documents. Providers must work with their internal IT staff to download these documents.

The MCE lists each edit code requirement which CMS uses to avoid inappropriate payment on inpatient claims. Updates are made to the MCE on a quarterly basis. CMS publishes a comparison document which lists the quarterly changes made to the MCE manual for the specific year. Chapter 1: Edit code lists includes specific edit code lists used to find errors based on coding. The categories are:

  • Invalid diagnosis or procedure code
  • External causes of morbidity codes as principal diagnosis
    • Ensures external (V, W, X, or Y code) diagnosis codes is not listed as primary diagnosis code
  • Duplicate of Primary Diagnosis
  • Age conflict
    • Newborn diagnoses
    • Pediatric diagnoses (age 0 through 17)
    • Maternity diagnoses (age 12 through 55)
    • Adult diagnoses (age 15 through 124)
  • Sex conflict
    • Diagnoses for females only
    • Procedures for females only
    • Diagnoses for males only
    • Procedures for males only
  • Manifestation code as principal diagnosis
    • Manifestation codes not allowed as principal diagnosis
  • Questionable admission codes
    • Lists specific diagnosis not usually sufficient to justify admission
  • Unacceptable principal diagnosis codes
    • Requires secondary diagnosis code to support principal diagnosis
  • Non-covered procedure codes
    • Always non-covered procedures
    • Non-covered procedures allowed with specific diagnosis
    • Procedures non-covered with specific diagnosis
    • Non-covered procedures based on age
  • Invalid age and sex
    • Ensures the patient age is between zero years and 124 years of age and the gender is appropriate for the Diagnosis Related Grouper (DRG)
  • Invalid sex
  • Invalid discharge status
  • Limited coverage
    • Reviews coverage for certain procedures where medical complexity and serious nature incur extraordinary associated costs. Medicare limits coverage to a portion of the cost
  • Wrong procedure performed
  • Procedure inconsistent with length of stay (LOS)
    • Only applies to 5A1955Z when LOS is four days or greater

Resources

 

Last Updated Fri, 24 Jul 2020 14:02:45 +0000